Search Results (192)

Background and Objectives: We aimed to evaluate early postoperative radiographic changes in sagittal foot alignment following laparoscopic sleeve gastrectomy and to investigate the association between early weight loss and sagittal foot alignment parameters. Materials and Methods: This study included 72 consecutive patients who underwent primary laparoscopic sleeve gastrectomy. Standardized lateral foot radiographs were obtained preoperatively and at the fourth postoperative month. Meary’s angle, calcaneal pitch, and talar declination angle were measured on all radiographs. Demographic and clinical variables, including age, sex, height, body weight, and body mass index (BMI), were recorded. Results: Meary’s angle demonstrated a significant postoperative decrease from 15° (IQR, 8°) to 11° (IQR, 12°) (p < 0.001), indicating improvement in medial longitudinal arch alignment. In contrast, no significant postoperative changes were observed in the calcaneal pitch (p = 0.227) or talar declination angles (p = 0.751). The proportion of patients within the normal range for all measured sagittal alignment parameters increased postoperatively, without showing statistical significance. Statistical analysis revealed that all postoperative sagittal alignment parameters showed significant correlation with preoperative values. Notably, postoperative Meary’s angle demonstrated a very strong positive correlation with preoperative Meary’s angle (r = 0.80, p < 0.001), whereas no significant correlation was identified between postoperative Meary’s angle and either postoperative weight or weight/BMI loss (p > 0.05). Although BMI loss showed a significant correlation with postoperative calcaneal pitch and talar declination angles, these correlations were weak to moderate (r = −0.403, and r = −0.362, respectively). Conclusions: Early postoperative body weight/BMI loss following sleeve gastrectomy is associated with modest, parameter-specific improvements in sagittal foot alignment, primarily reflected by changes in Meary’s angle, suggesting that the medial longitudinal arch may be more responsive to early postoperative unloading than other sagittal alignment parameters. The strong association between preoperative and postoperative measurements underscores the central role of baseline alignment in determining early postoperative outcomes. Full article

Background/Objectives: Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure worldwide; one-anastomosis gastric bypass (OAGB) ranks third. Gastroesophageal reflux disease (GERD) may develop de novo or worsen following either procedure. This systematic review and meta-analysis aimed to compare postoperative GERD outcomes—overall, de novo, and persistent—between LSG and OAGB. Methods: A PRISMA-compliant systematic review and meta-analysis were conducted. PubMed, Embase, the Cochrane Library, and Web of Science were searched for studies published between January 2000 and December 2025. A random-effects model was applied for the meta-analysis. Results: A total of 847 articles were identified. Among them, 15 primary studies met the inclusion criteria (four randomized controlled trials and 11 observational studies involving approximately 1800 LSG and 2450 OAGB patients). LSG was associated with a significantly higher risk of overall GERD (OR, 3.67; 95% CI, 2.54–5.30; p < 0.001; I² = 55%), de novo GERD (OR, 4.12; 95% CI, 2.54–6.69; p < 0.001; I² = 44%), and persistent or worsening GERD (OR, 2.67; 95% CI, 1.34–5.32; p = 0.005; I² = 38%). Hiatal hernia was reported in only four studies; bile reflux was paradoxically higher after LSG than OAGB (74.7% vs. 12.5%). Conclusions: LSG carries significantly higher postoperative GERD risk than OAGB across all evaluated outcomes. Although Roux-en-Y gastric bypass remains the gold standard for bariatric patients requiring GERD control, OAGB represents a well-supported alternative that outperforms LSG in reflux-related outcomes and should be favored when GERD is a clinical concern. Full article

Background: Early postoperative changes in creatinine-based estimated glomerular filtration rate (eGFR) after bariatric surgery can be misread as a kidney injury. During rapid weight loss, indexing eGFR to a fixed body surface area (BSA) of 1.73 m² may alter apparent trajectories. We compared absolute (mL/min) and BSA-indexed (mL/min/1.73 m²) eGFR changes after sleeve gastrectomy, stratified by baseline glomerular hyperfiltration (GH). Methods: In this retrospective cohort of 145 adults undergoing laparoscopic sleeve gastrectomy, serum creatinine was obtained at baseline (≤30 days pre-op) and 3 months (post-op days 75–105). Indexed eGFR was calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 creatinine equation; BSA with the Mosteller formula; and absolute eGFR as indexed eGFR × (BSA/1.73). GH was defined as indexed eGFR ≥ 120 mL/min/1.73 m². A REML mixed-effects model (Group, Time, Group × Time) with patient-cluster bootstrap inference was used. An age-adjusted sensitivity model including Age and Age × Time was also fitted. Results: Fifty-four participants (37%) met the GH criteria. Absolute eGFR declined by −26.6 mL/min in GH versus −17.3 mL/min in non-GH (difference-in-differences [DiD] −9.3 mL/min; 95% CI −13.9 to −4.7; p < 0.001). The indexed eGFR changes were smaller (−4.2 vs. −0.5 mL/min/1.73 m²; DiD −3.7; 95% CI −7.3 to −0.03; p = 0.048; bootstrap p_sign = 0.052). In the age-adjusted sensitivity model, the Group × Time interaction for absolute eGFR attenuated but remained statistically significant (−6.57 mL/min; 95% CI, −13.09 to −0.06; p = 0.048), whereas the corresponding interaction for indexed eGFR was attenuated and no longer statistically significant (−3.99 mL/min/1.73 m²; 95% CI −9.15 to 1.16; p = 0.129). Conclusions: Within three months after sleeve gastrectomy, participants with higher baseline indexed filtration showed a larger decline in absolute eGFR but only a small change in indexed eGFR. These results show that early postoperative creatinine-based eGFR trajectories are scale dependent and should be interpreted cautiously during rapid weight loss. Because postoperative acute kidney injury (AKI) was not adjudicated and direct kidney function markers were unavailable, this study does not distinguish physiological hemodynamic change from structural kidney injury. Reporting both absolute and indexed eGFR may improve early postoperative interpretation and help align dosing decisions with rapid changes in body size. Full article

Background and Objectives: This study investigated the correlation of the liver-to-spleen (L/S) Hounsfield unit ratio on abdominal CT with liver function and diabetic indicators before and after laparoscopic sleeve gastrectomy (LSG), comparing patients with and without diabetes mellitus (DM and non-DM groups). Methods: Patients undergoing LSG were categorized into DM and non-DM groups. Metabolic parameters and abdominal CT scans were assessed preoperatively and one year postoperatively. Correlations among these variables were analyzed, and intergroup comparisons were performed. Results: Preoperative body weight and postoperative weight loss were comparable between the DM and non-DM groups. Before surgery, the DM group showed significantly higher levels of fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), aspartate transaminase (AST), alanine transaminase (ALT), and γ-glutamyl transpeptidase (γ-GTP). After LSG, both groups exhibited significant reductions in FPG, HbA1c, AST, ALT, and γ-GTP, along with a significant increase in the L/S ratio. The reduction in γ-GTP was more pronounced in the DM group. In the DM group, changes in glycemic markers (FPG and HbA1c) were significantly correlated with changes in liver enzymes and with the change in L/S ratio. Conclusions: LSG reduced body weight and fat mass and improved glucose metabolism and liver function in patients with obesity, regardless of their diabetes status. Improvements in liver enzymes and/or the L/S ratio were more marked in diabetic patients and might be closely linked to better glycemic control following surgery. Full article

Background and Objectives: This study aimed to evaluate the safety and feasibility of reduced-port laparoscopic distal gastrectomy (RPLDG) in elderly patients. Materials and Methods: Electronic medical records of 226 patients who underwent RPLDG performed by a single high-volume surgeon at a single institution (Chonnam National University Hospital) between January 2015 and April 2020 were retrospectively analyzed. Among these patients, 60 were aged ≥ 75 years (elderly group), and 166 were younger than 75 years (non-elderly group). Patient characteristics, surgical outcomes, and short-term postoperative outcomes were compared between the two groups. Results: Surgical outcomes were comparable between the age groups. However, medical complication events, assessed using an event-based approach allowing multiple events per patient, were more frequent in patients aged ≥ 75 years. Compared with the non-elderly group, the elderly group demonstrated a higher frequency of overall postoperative complication events (18 [30%] vs. 29 [18%], p = 0.040), primarily attributable to medical complications (9 [15%] vs. 6 [4%], p < 0.01). The elderly group also showed a delayed time to first gas passage (3.5 [3.0–4.0] vs. 3.0 [3.0–3.0] days, p < 0.001). However, no statistically significant differences were observed in length of hospital stay (7.0 [6.0–10.0] vs. 6.0 [6.0–8.0] days, p = 0.262) or intraoperative blood loss (p = 0.831). No significant differences were found in surgical complication events (p = 0.05) or Clavien–Dindo grade ≥ 3 complication events (p = 0.13). In the risk factor analysis for complications, univariate analysis identified age ≥ 75 years as a significant factor. However, in the multivariate analysis, only respiratory comorbidities, liver disease, and poor ECOG performance status remained independent risk factors, whereas age ≥ 75 years was no longer statistically significant (p = 0.193). The finding regarding liver disease should be interpreted with caution because of the extremely small sample size. Conclusions: RPLDG appears to be a viable surgical option for patients aged ≥ 75 years, demonstrating acceptable surgical outcomes and severe complication rates comparable to those observed in non-elderly patients. Full article

Background/Objectives: Completion of perioperative systemic therapy is essential for improving survival in patients with locally advanced gastric adenocarcinoma; however, many patients do not receive planned adjuvant therapy because of surgical complications or inadequate recovery. Robotic gastrectomy may improve postoperative recovery and facilitate adjuvant therapy delivery, but contemporary national data remain limited. This study evaluated the association between surgical approach and adjuvant systemic therapy utilization. Methods: Adults with non-metastatic, locally advanced (>pT2N0 or received neoadjuvant chemotherapy) gastric adenocarcinoma who underwent gastrectomy from 2016 to 2021 were identified from the National Cancer Database. Patients who met the criteria for adjuvant systemic therapy were included. Propensity score matching was performed to compare robotic gastrectomy (RG) with laparoscopic gastrectomy (LG) and open gastrectomy (OG). The primary outcome was receipt of adjuvant systemic therapy (ASTx). The secondary outcomes included days from surgery to ASTx initiation, perioperative outcomes, oncologic quality metrics, and overall survival. Results: Among 5853 eligible patients, 17.8% underwent RG. After propensity score matching, ASTx utilization was similar between RG and LG (43.6% vs. 43.9%, p = 0.946) and between RG and OG (44.5% vs. 48.0%, p = 0.144), with no differences in days from surgery to ASTx initiation. Compared with LG, RG was associated with higher R0 resection rates but higher unplanned 30-day readmission rates. Compared with OG, RG was associated with higher R0 resection rates, greater regional lymph node examination, shorter length of stay, and lower 90-day mortality rates. Overall survival rates did not significantly differ between approaches. Conclusions: In this contemporary national analysis, RG did not result in improved delivery or timing of adjuvant systemic therapy despite favorable perioperative outcomes. These findings suggest that considering surgical approach alone is insufficient to address barriers to completion of multimodality therapy in gastric cancer. Full article

Background/Objectives: Laparoscopic sleeve gastrectomy (LSG) treats severe obesity, but data on its effects on 24 h blood pressure (BP) patterns, blood pressure variability (BPV), and cardiac autonomic nervous system (CANS) in obese patients without hypertension or diabetes are limited. We evaluated these parameters before and after LSG. Methods: 78 patients with severe obesity (BMI ≥ 40 kg/m²) without hypertension or diabetes who underwent LSG between January 2016 and December 2019 were included in the study. Patients underwent ambulatory blood pressure monitoring (ABPM), ambulatory electrocardiographic monitoring, and laboratory tests before and six months after surgery. Results: Preoperative ABPM was characterized by a significant proportion of masked hypertension (43.5%), high 24 h BP (mean SBP 138.9 ± 5.5 mmHg, DBP 81.1 ± 4.9 mmHg), high BP load (39% SBP, 38% DBP), and a non-dipper pattern (67.9%). After LSG, significant improvements were observed in mean 24 h SBP, DBP (p < 0.001), BPV, BP load, and non-dipper patterns. HRV parameters (SDANN, RMSSD) increased significantly (p < 0.001) and HRT parameters improved: TO became more negative from −0.54 ± 1.73 to −2.53 ± 1.97, TS increased from 5.98 ± 3.49 to 9.87 ± 4.28 ms/RR (p < 0.001). We found a strong association between decreased body mass index and BP changes. Changes in glucose, HbA1c, and HOMA-IR predicted CANS improvement (β = 0.24–0.38; R² = 20.8–29.7%). Conclusions: Six months after LSG, significant improvements in BP, BPV, and CANS were observed. BP reduction was primarily associated with weight loss, while glucose control was associated with autonomic improvements. LSG was associated with early improvements in surrogate cardiovascular risk markers through combined weight-dependent and metabolic-hormonal mechanisms. Full article

Background/Objective: Bariatric surgery is an established treatment for individuals with severe obesity, providing sustained weight loss and improvement in obesity-related comorbidities. However, evidence on long-term outcomes and predictors of metabolic resolution, particularly among Asian populations, remains limited. We aimed to evaluate metabolic outcomes after bariatric surgery and identify predictive factors associated with remission. Methods: We retrospectively reviewed the data of 581 patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at a tertiary care center between January 2012 and December 2022. Surgical techniques, postoperative follow-up, and baseline characteristics were recorded. Remission and improvement of metabolic comorbidities were assessed during 1–5 years of follow-up. Predictive factors were analyzed, and remission rates between SG and RYGB were compared using propensity score matching. Results: A total of 154 (26.5%) individuals had type 2 diabetes mellitus (T2DM), 162 (27.8%) hypertension (HT), 173 (29.7%) dyslipidemia (DLP), and 407 (70.0%) metabolic syndrome (MetS). Remission occurred in 79.1% of individuals with T2DM, 36.0% with HT, 33.9% with DLP, and 79.6% with MetS. Predictive factors included T2DM duration < 3 years, younger age for HT and DLP remission, male sex, body mass index < 43 kg/m², and fasting blood glucose level < 126 mg/dL for MetS. RYGB achieved higher remission of DLP than did SG, whereas other outcomes were comparable. Conclusions: Bariatric surgery effectively improves metabolic comorbidities, and several predictive factors influence outcomes. RYGB resulted in superior remission of DLP, while other metabolic outcomes were comparable between the two procedures. Full article

Background/Objectives: Robot-assisted gastrointestinal (GI) cancer surgery has expanded in Japan since national reimbursement in 2018, yet hospital profitability remains uncertain because of capital, maintenance, and consumable costs. We examined whether a program-level volume threshold for profitability exists under Japan’s fee schedule and quantified actionable improvement targets. Methods: We developed a hospital-perspective, model-based economic evaluation (index admission to 30 days; 2025 Japanese yen (JPY)) comparing robot-assisted surgery (RAS) with conventional laparoscopic surgery (CLS) under Japan’s fee schedule (one point = ¥10) for gastrectomy, colectomy, rectal resection, and pancreatoduodenectomy. Case-level contribution margin differentials (ΔCM) were defined as the revenue differential minus the consumables differential and additional operating room (OR) time costs, plus savings from reduced length of stay (LOS), and were aggregated to annual program profit (Π) after fixed costs and platform sharing. Primary outputs were allowable consumables, required cut (%), and isoprofit contours. Uncertainty was assessed using 50,000-iteration probabilistic sensitivity analysis (PSA), one-way sensitivity analysis (OWSA), and learning-curve scenarios in line with Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022. Results: In the base case, ΔCM was predominantly ≤0 for colon, rectum, and pancreatoduodenectomy; therefore, when the case-mix-weighted mean ΔCM was ≤0, increasing volume could not achieve breakeven and instead increased losses. Each 10 min reduction in OR time increased allowable consumables by ¥15,000, and each bed-day reduction increased it by ¥30,000. These required-cut and isoprofit maps provide actionable targets for cost negotiation, operational improvement, and platform sharing. Conclusions: Volume expansion alone rarely yields profitability; coordinated reductions in consumables, OR time, and LOS, together with platform sharing, are required. Full article

Background and Objectives: Obesity is a major contributor to female reproductive dysfunction, frequently resulting in menstrual irregularity, anovulation, and subfertility. Bariatric surgery improves metabolic health; however, its effect on reproductive outcomes—particularly the shift from assisted to spontaneous conception—remains incompletely defined. This study aimed to evaluate the impact of laparoscopic sleeve gastrectomy (LSG) on menstrual cycle regularity and spontaneous pregnancy rates in women of reproductive age. Materials and Methods: This retrospective observational study included 52 women aged 18–40 years who underwent LSG between January 2013 and October 2017. Self-reported menstrual history, as documented during routine preoperative assessment in the electronic medical records, and reproductive outcomes (including spontaneous and assisted conception) were compared between the preoperative and postoperative periods. The median follow-up duration was 38 months. Results: A significant improvement in menstrual regularity was observed (46.2% to 94.2%, p < 0.001). Among women attempting conception, 10/15 (66.7%) achieved spontaneous pregnancy; one conceived via ART. Notably, 57.1% of all pregnancies occurred within the first 12 months post-surgery, including three unintended conceptions. Additionally, among women who conceived spontaneously, four had a history of requiring assisted reproductive technologies (ART), including two who had previously failed to conceive despite ART treatment. Conclusions: LSG is associated with significant normalization of menstrual cycles and a qualitative shift toward spontaneous conception in morbidly obese women. The rapid return of fertility, which may exceed patient awareness, underscores the importance of comprehensive perioperative counseling regarding effective contraception to prevent unintended pregnancies during the active weight-loss phase. Full article

Background: Identifying differences between genders regarding long-term surgical outcomes in bariatric surgeries may be important for optimizing their results. Objective: The current study evaluated mid-term gender-specific differences in patients undergoing laparoscopic sleeve gastrectomy (LSG). Methods: A retrospective cohort study was done in our university-based hospital, including patients who underwent laparoscopic Sleeve Gastrectomy (LSG) between January 2014 and December 2017. We compared demographics and clinical history (including BMI) before and after surgery, as well as the Bariatric Analysis and Reporting Outcome System (BAROS) and complications. Results: We enrolled 217 patients, 86 of whom were males (39.6%), with an average age of 52 ± 0.8 years. We observed no significant differences between males and females in minimal BMI attained (26.35 ± 4.9 vs. 25.9 ± 4.5 respectively, p = 0.56), total complications rate (p = 0.165), early post-op complication rate (p = 0.158), need for re-operation (p = 0.357), and BAROS score (p = 0.42). Conclusions: LSG outcomes were similar for male and female patients, as measured by BAROS, BMI reduction, and complication rates. Further studies are warranted; however, in the meantime, LSG can be offered to the entire population, regardless of gender-specific considerations. Full article

Background/Objectives: Target-controlled infusion (TCI) with remifentanil or sufentanil provides stable and effective anesthesia. This randomized prospective trial investigated the comparative efficacy of TCI using sufentanil versus remifentanil on postoperative analgesia and recovery profiles in patients after laparoscopic subtotal gastrectomy under remimazolam-based total intravenous anesthesia (TIVA). Methods: Sixty-six patients who underwent laparoscopic subtotal gastrectomy were randomly allocated to receive either TCI-based sufentanil or remifentanil in TIVA with remimazolam. The primary endpoint was the cumulative fentanyl consumption within 24 h after surgery. The secondary outcomes were pain intensity at rest and during activity, and recovery parameters including time to extubation, length of post-anesthesia care unit (PACU) stay, and quality of recovery (QoR-40) on postoperative day 1 (POD1). Results: The cumulative fentanyl consumption over the 24 h postoperative period was similar between the two groups. However, compared with the remifentanil group, the sufentanil group required significantly less fentanyl during the immediate postoperative period (0–0.5 h) (p < 0.001) and exhibited lower pain scores both at rest and during activity during the first postoperative hour (p < 0.001). Although the Sedation-Agitation Scale score at PACU admission was significantly lower in the sufentanil group (p < 0.001), the overall recovery profiles, including time to extubation, PACU stay, and QoR-40 scores on POD 1, were comparable between the groups. Conclusions: TCI-based sufentanil and remifentanil in TIVA with remimazolam showed similar overall analgesic efficacies and recovery outcomes after laparoscopic subtotal gastrectomy. Both opioid strategies are effective for postoperative pain management, with a slight advantage in immediate postoperative pain control for sufentanil. Full article

Objective: To compare the clinical and metabolic impact of the relationship between leptin, serum soluble leptin receptor (sOB-R), free leptin index (FLI), and ghrelin among different metabolic and bariatric surgeries (MBSs) in patients with severe obesity. Method: Cohort study including 194 patients >18 years old diagnosed with obesity (body mass index (BMI) ≥ 30 kg/m²) undergoing bariatric surgery at the General Hospital of Mexico. Participants were distributed into three surgical groups: Roux-en-Y gastric bypass (RYGB) (n = 36), one anastomosis gastric bypass (OAGB) (n = 86), and sleeve gastrectomy (SG) (n = 72); all operations were performed laparoscopically. Pre- and post-surgical measurements were taken, including anthropometric measurements, lipid profile, glycated hemoglobin (HbA1c), leptin, sOB-R, ghrelin, and FLI. Protocol registration: DI/16/304/04/090. Results: A total of 194 patients with obesity were analyzed, the average weight was 114.9 ± 24 kg, and the preoperative BMI was 43.1 ± 8.0 kg/m². Three types of MBSs were compared. Post-surgery, all groups showed a significant percentage of excess weight loss (%EWL), for example, in OAGB 65.6 ± 12.2%EWL at 12 months (p < 0.0001). In addition, ghrelin levels decreased significantly, especially in a short time compared with pre-surgery levels (from 4 ± 2.5 to 1.6 ± 1 ng/mL per first week (p < 0.0001)). Similarly, leptin diminished in a short time (p < 0.01). Soluble leptin receptor showed differences in the biochemical behavior of leptin, with FLI decreasing significantly (p < 0.003) after one year (p = 0.001). Conclusions: All techniques were effective in reducing body weight, %EWL, and hormonal modulation during the first three months. In addition, ghrelin and FLI levels partially increased as a physiological adaptation to weight loss and resumption of food intake, without reaching initial values. Full article

The vascular anatomy of the stomach is both complex and highly variable, with direct implications for oncologic, bariatric, esophageal, and interventional procedures. This comprehensive review combines anatomical, radiological, and surgical evidence on arterial and venous variations in the stomach. The left gastric artery, traditionally the first branch of the coeliac trunk, often shows variants such as a direct aortic origin or association with an abnormal left hepatic artery. The right gastric artery most frequently arises from the proper hepatic artery, but its origin can vary significantly. The gastroepiploic arteries exhibit diversity in their origin, size, and connection patterns, with occasional duplication or absence. Additional vessels, including the posterior gastric artery and the short gastric arteries, also contribute to variations in arterial supply. Venous drainage largely follows the arterial pattern. The left and right gastric veins and the gastroepiploic venous arcade are major routes, while variants of the left gastric vein and the gastrocolic trunk (Henle’s trunk) contribute to complexity through different convergence patterns. These vascular variations have significant clinical implications, as they impact the safety of D2 lymphadenectomy, the risk of ischemic complications during laparoscopic sleeve gastrectomy, the success of gastric conduit formation in esophagectomy, and the effectiveness of transarterial embolization for upper gastrointestinal bleeding. Preoperative vascular mapping with multidetector computed tomography angiography and 3D reconstruction reliably defines individual anatomy, allowing for customized surgical planning and reducing operative risks. Recognizing both common and rare gastric vascular variants is essential for safe and effective surgical and endovascular management of gastric disease. Full article

A 60-year-old woman with hypertension and hyperlipidemia was referred for an incidentally detected gastric subepithelial mass during screening endoscopy. Esophagogastroduodenoscopy revealed a 10 mm dimple in the antrum, and contrast-enhanced CT showed a 2.5 cm enhancing oval lesion. Laparoscopic partial gastrectomy with intraoperative endoscopic guidance was performed. Gross examination revealed a 3.0 × 2.0 × 1.0 cm pale, firm nodule. Histology showed small round cells arranged in nests and trabeculae within the muscularis propria, with numerous vessels and focal calcification. Immunohistochemistry was negative for CD117, HMB45, and chromogranin A, but demonstrated strong smooth muscle actin positivity, weak synaptophysin reactivity, and focal CD56 staining. The findings confirmed a gastric glomus tumor with neuroendocrine features. Smooth muscle actin immunostaining is essential to distinguish gastric glomus tumors from neuroendocrine tumors when biopsy material is limited, ensuring accurate diagnosis and appropriate management. Full article